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Thoracic Surgery Donovan Campbell 4th Year Medical Student Queen's University Belfast Supervised by Mr Peter Mhandu Specialty Doctor in Cardiothoracic Surgery, Royal Victoria Hospital BelfHospital Dublinllow Robotic Surgery MaterThanks to our partners! Learning Outcomes Anatomy Clinical o Mediastinum o Lung Cancer Classification o Thoracic Wall o Risk Factors o Tracheobronchial Tree o Clinical Features o Lungs and Pleurae o Investigations o Neurovasculature o Metastatic Disease o Lymphatics o Management OptionsAnatomy Mediastinum The mediastinum is the central compartment of the thoracic cavity. The thoracic plane of Ludwig, is an imaginary line that extends from the sternal angle, to the T4-T5 intervertebral space. This plane divides the mediastinum into superior and inferior mediastinal planes. The inferior mediastinum is further subdivided into anterior, middle and posterior compartments by the pericardial sac. https://www.lecturio.com/concepts/mediastinum-and-great-vessels/ Superior Mediastinum Borders Contents – Private Left Battle Superior – Thoracic inlet (aperture). Phrenic N. Vagus N. Inferior – The transverse plane of Ludwig. Thoracic Duct Anterior – Manubrium. Left recurrent laryngeal N. Posterior – Vertebral bodies of T1-4. Brachiocephalic Vein Lateral – Pleurae of the lungs. Aortic Arch Thymus Trachea Lymph node Oesophagus Anterior Mediastinum Borders Contents Lateral borders - Mediastinal pleurae. Thymus Sterno-pericardial ligaments Anterior border - Sternal Lower pole of thyroid gland body and transversus thoracis muscles. Internal thoracic vessels Posterior border - Pericardium. Para-sternal lymph nodes Roof - The transverse plane of Ludwig. Floor - Diaphragm. Clinical Relevance – All the T's • Teratoma • Thymic carcinomas/thymomas • Thyroid Carcinomas du/patientcare/surgery/patient-e • Terrible Lymphomas about-mediastinal-tumors-and-their- management Middle Mediastinum Contents Heart – enclosed in the pericardium. Great Vessels – Pulmonary Trunk, root of the aorta, root of SVC + IVC and pulmonary arteries and veins. Pericardiophrenic vessels. Arch of Azygous vein. Bifurcation of the trachea (carina) Main bronchi. Right + Left Phrenic N. https://quizlet.com/158680691/211-middle-mediastinum-flash-cards/https://app.medall.org/even t-listings/cardiac-surgery- and-anatomy Posterior Mediastinum Contents – DATES Borders Lateral - Mediastinal pleura. Descending Aorta Anterior - Pericardium. Azygous/hemiazygous veins Posterior - T5-T12 vertebrae. Thoracic Duct Oesophagus Roof - The transverse plane of Ludwig. Sympathetic Chain Floor - Diaphragm. Vagus Nerve – Anterior + Clinical Relevance Posterior Trunks Descending Aortic Aneurysms Thoracic Wall The Sternum Support and Protect Manubrium • Jugular notch • clavicular notch • 1st costal notch • 2nd costal notch Body • 2nd-7th costal notches • Two and seven are demifacets Xiphoid Process • Cartilaginous originally > ossifies ~ 40 years old. • T10. Thoracic Cage Typical Ribs Clinical Relevance • Ribs 3-9. • Contains of a head, neck and Flail Chest body. Atypical Ribs Traumatic condition that • 1,2,10-12. occurs when two or more ribs located next to each other are fractured in two or more •Rib 1 – Only one facet for places. articulation with its corresponding vertebra. Causes paradoxical breathing. •Rib 2 - Tuberosity from which serratus anterior originates. Haemodynamic compromise. •Rib 10 - Only one facet. •Ribs 11 - 12 No neck and only contain one facet. https://www.sciencedirect.com/science/article/abs/pii/S154741270600106X Thoracic Vertebrae Heart shaped Typically, demi-facet > head of ribsThoracic Wall Chest Drain Insertion Incise + dissect using Roberts ABOVE the rib. Tracheobronchial Tree T4/5 https://www.lecturio.com/concepts/bronchial-tree/What type of cells do the Trachea and the main bronchi consist of? A – Simple Columnar Epithelial Cells B – Ciliated Pseudostratified Columnar Epithelium C – Simple Squamous Epithelial Cells D – Ciliated Stratified Columnar Epithelium E – Simple Stratified Columnar EpitheliumWhat type of cells do the Trachea and the main bronchi consist of? A – Simple Columnar Epithelial Cells B – Ciliated Pseudostratified Columnar Epithelium C – Simple Squamous Epithelial Cells D – Ciliated Stratified Columnar Epithelium E – Simple Stratified Columnar EpitheliumTrachea Tracheostomy A tracheostomy is an opening surgically created through the neck into the trachea. The person with a tracheotomy breathes through the trach tube rather than through the nose and mouth. May be temporary or permanent. https://www.nejm.org/doi/full/10.1056/NEJMvcm2014884 The Lungs and Pleurae Remember Pneumothorax! Gray's Anatomy The Lungs Impressions https://www.instantanatomy.net/thorax/areas/respiratorysystem/impressions.htmlThe Lung Segments http://thorax.bmj.com/content/56/2/89.fullArteries https://teachmeanatomy.info/abdomen/vasculature/arteries/aorta/ Arteries https://surgicalnotes633341655.wordpress.com/2019/12/24/thoracic-wall-blood-supply/ Arteries Summary Aorta The lungs are supplied with deoxygenated blood by the pulmonary arteries. Aortic Arch: 1) Brachiocephalic A Once the blood has received oxygen, it leaves 2) L Common Carotid A the lungs via four pulmonary veins. 3) L Subclavian A Subclavian – VITCD The bronchi, lung roots, visceral pleura and V – Vertebral supporting lung tissues are supplied by I – Internal Thoracic (LIMA+RIMA Grafts) the bronchial arteries, which arise from the T – Thyrocervical Trunk descending aorta, T5-6. C – Costocervical Trunk D – Dorsal Scapular Venous Supply Superior Vena Cava Obstruction https://courses.lumenlearning.com/suny-ap2/chapter/circulatory-pathways/ Venous Supply Gray's Anatomy Venous Summary The bronchial veins provide venous drainage. The right bronchial vein drains into the azygos vein. The left drains into the accessory hemiazygos vein. https://drsvenkatesan.com/2016/06/28/where-does-bronchial-veins-drain/ Nervous System Pulmonary Plexus – Anterior + Posterior. Parasympathetic – from the vagus nerve. They stimulate secretion from the bronchial glands, contraction of the bronchial smooth muscle and vasodilation of the pulmonary vessels. Sympathetic – derived from the sympathetic trunks. They stimulate relaxation of the bronchial smooth muscle, and vasoconstriction of the pulmonary vessels. Visceral afferent – conduct pain impulses to the sensory ganglion of the vagus nerve. Pleural Nervous System Parietal Pleura Sensitive to pain, temperature, touch and pressure. • Costal Pleura – supplied by intercostal nerves. • Mediastinal pleura – phrenic nerve. • Diaphragmatic Pleura – centre by phrenic nerves and peripherals by intercostal nerves. Visceral Pleura Sensitive to stretch not pain or touch! Autonomic supply from the pulmonary plexus. Lymphatic System http://msgallagherlhs.weebly.com/lymphatic-system-structures.html http://www.nucmedresource.com/thoracic-nodal-stations.html Clinical Relevance Chylothorax – leakage of chyle into the thorax. Causes - Iatrogenic, malignancy, trauma, congenital, infection...Lymphatic System Oesophagus Fibromuscular tube 25 cm in length, mucosal layer consisting of non-keratinising stratified squamous epithelium. Origin – cricoid cartilage (c6) Insertion – cardiac orifice (T11) Arterial Supply • Oesophageal branches of inferior thyroid artery (thyrocervical). • Oesophageal branches of aorta. • Right intercostal arteries. Venous • Branches of the azygous veins • Inferior thyroid vein. Nerve Barrett's Oesophagus • Oesophageal plexus. Metaplasia > columnar epithelium. • Parasympathetic vagal trunks • Sympathetic fibres from the cervical and thoracic sympathetic (Adenocarcinoma) trunks. Squamous cell carcinoma – most prevalentWhat vertebral level does the oesophagus pass through the diaphragm? A – T8 B – T9 C – T10 D – T11 E – T12 What vertebral level does the oesophagus pass through the diaphragm? REMINDER "Oesophagus" A – T8 10 letters B – T9 C – T10 D – T11 E – T12 Diaphragm T8 Inferior Vena Cava Caval Hiatus Right Phrenic N T10 Oesophagus OesophagealHiatus R+L Vagus NN Oesophageal branches of LGA/V T12 Aorta Aortic Hiatus Thoracic Duct Azygous Vein C3,4,5 KEEP.....Clinical Lung Cancer Classification Adenocarcinoma 40% 85% Squamous Cell Carcinoma 25% Non-Small Cell Carcinoma Large Cell Lung Cancer Carinoma 10% Small Cell Carcinoma Carcinoid 1-2% 15% Types of Lung Cancer Type Adeno Squamous Large Cell Carcinoid SCLC Meso Location Peripheral Central Mixed Mixed Central Pleura Signs Mucin++ HTOP Cavitating lesion. Gynaecomastia Carcinoid Syndro SIADH Pleural Effusion HTOP me R.F. Smoking Smoking Smoking Not smoking? Smoking Asbestos Female Histology Glandular Keratin Pearl Large cells NET Salt and Epithelioid NET pepper chromatin. Biphasic NET Desmoplastic Investigations CT FNA Flexible Bronchos Flexible Flexible Flexible CT Pleura Navigational copy Bronchoscopy Bronchoscopy Bronchoscopy Effusion analysis Bronchoscopy CT FNA CT FNA – O&S Rx Surgery Surgery Surgery Surgery Chemo-rad Palliative, Pleurect omy Extra Most common Hypercalcaemia Met Early (CNS) 5-HIAA Lambert Eaton Long Non-smokers Latent Period Adenocarcinoma • Peripherally located • Most common type of lung cancer • Most prevalent in non-smokers - (although ~80% are smokers) • Formed from glandularstructures in the epithelium (mucus secreting glands.) • Hypertrophic osteoarthritis o Finger clubbing o Bone swelling o Arthritis • Mucin ++ • Gynaecomastia! Squamous Cell Carcinoma • Typically central Keratin Pearls • Very Strong Association with smoking • Can secrete parathyroid hormone- related protein (PTHrP) → hypercalcaemia • Finger clubbing +++ • Cavitating lesions Cavitating Lesions • Hypertrophic pulmonary osteoarthropathy (HPOA) • Hard to visualise on X-ray https://medizzy.com/feed/372036https://librepathology.org/wiki/Squamous_cell_carcinoma Large Cell Carcinoma Large cell carcinoma are an aggressive NSCLC tumour, most commonly manifesting as large, necrotic masses that invade adjacent structures. Mixed location but > % are peripheral. Present with typical respiratory signs + commonly signs of metastases (CNS.) • Bony pain • Headache • Seizures • Large cell size Radiologically • Prominent nucleoli, • Hilar and mediastinal lymphadenopathies are • Moderate amount of cytoplasm. common findings. May secrete β-hCG Poor prognosis! Small Cell Carcinoma Rapidly growing with early metastases. Often presents at late stage. Arise from neuroendocrine cells (APUD). SMOKING • Central location • Ectopic ADH, ACTH secretion Salt and Pepper Chromatin • ADH → hyponatraemia (SIADH) • ACTH → Cushing's syndrome • Mostly metastatic (60%) • Very early-stage disease (T1-2a, N0, M0) Paraneoplastic Syndromes considered for surgery. (NICE) • Most patients receive a combination of chemotherapy and radiotherapy • Lambert Eaton Myasthenic Syndrome • Patients with more extensive disease are offered • Limbic Encephalitis palliative chemotherapy Carcinoid Tumour This is a rare tumour that originates from neuroendocrine cells, thus secretes hormones (serotonin). 20% occur in the lung accounting for approximately 1% of lung malignancies. Some patients may present with symptoms of carcinoid syndrome: • Facial flushing • High blood pressure • Weight gain • Hirsutism • Diarrhoea Investigations Good Prognosis • Urinary 5-hydroxy indoleacetic acid (5-HIAA), a metabolite of serotonin • 24-hour urine free cortisol level (elevated) Risk Factors https://www.mediastorehouse.co.uk/science-photo- https://twitter.com/MeritMedical/status/1325830865230950401 library/lung-cancer-smoking-artwork-f007-6160-9315817.html x15-30 Risk Increase! General Signs and Symptoms Symptoms Common Signs ➢Persistent cough ➢Weight Loss ➢Haemoptysis ➢Finger Clubbing ➢Dyspnoea ➢Monophonic Wheeze ➢Pain (pleuritic) ➢Hoarseness ➢Recurrent Infections ➢Ptosis ➢Fatigue ➢Dysphagia Investigations CXR CT CAP PERIPHERAL CENTRAL CT FNA Flexible Bronchoscopy MDM Navigational Curative MDM Bronchoscopy PET CT EBUS TBNA +/- EUS FNA https://www.nice.org.uk/guidance/ng122/chapter/Diagno Mediastinoscopy sis-and-stagingRadiological Chest X-ray OSCE – DRo ABCDE • Details ( Ask for a previous to compare) • Radiographical Quality – rotation, inspiration, penetration and exposure. • Obvious abnormalities • Airway: trachea, carina, bronchi and hilar structures. • Breathing: lungs and pleura. • Cardiac: heart size and borders. • Diaphragm: including assessment of costophrenic angles. • Everything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and review areas. Artifacts. Tissue Sampling Central Peripheral Lesion LesionPenetration of the pre-tracheal fascia. Master Techniques in Surgery – Thoracic SurgeryMetastatic Disease https://www.sciencedirect. com/science/article/pii/S1 556086421017469Staging Key Points Guides Treatment Estimate Prognosis T – Tumour N – Nodes M – Metastasis Typically ➢ M1 no surgery ➢ N2+ no surgery types-grades/ancerresearchuk.org/about-cancer/lung-cancer/stages- Management Options Surgery Gold Standard Resectability VS Operability • Video assisted thorascopic surgery (VATS) • Thoracotomy (open) • Robotic assisted thorascopic surgery (RATS) Wedge resection, segmentectomy, lobectomy, bilobectomy, pneumonectomy.... Chemotherapy Radiotherapy • Stereotactic ablative radiotherapy (SABR) Immunotherapy • Watch this space. • Checkmate 816 etc Surgery Huge Variety - less is more?... Lobectomy – Gold standard. Removal of an entire lobe. Bilobectomy – removal of 2 lobes. Only R lung. Segmentectomy – removal of a segment of the lung. Can be muti-segment. Pneumonectomy – removal of entire lung. Wedge resection – removal of a very small piece of lung tissue. Sleeve resection – removal of lobe + segment of main bronchus is resected Chest wall resection – invasion of chest wall. Sarcoma. Preoperative Management Smoking Cessation Investigations - Pulmonary function tests - Exercise stress test Bloods Group and hold, crossmatch (2 units) and coag screen. Staging CT/PET Prehabilitation – MDT Dietician, anaesthetist. Thoracoscore – mortality risk score.Video Assisted Thoracoscopic Surgery (VATS) https://www.youtube.com/watch?v=rQxJDRD5f9QMaster Techniques in Surgery – Thoracic SurgeryMaster Techniques in Surgery – Thoracic SurgeryThoracotomy (Open) Clamshell Thoracotomy Usually reserved for emergency cases or rarely transplant. - Bilateral pulmonary adhesions. - Bilateral pulmonary mets. Incision hidden in inframammary crease. Master Techniques in Surgery – Thoracic Surgery Robotic Assisted Thoracoscopic Surgery (RATS) Recognised benefits • Smaller scars • Less blood loss • Less pain after the operation • Shorter hospital stays – most patients go home after two nights. • Quicker full recover – recovery time averages two weeks with fewer complications. • More accurate prognosis and diagnosis – more thorough dissection of lymph nodes and a precise assessment of lymph node can be made. Cost vs benefit analysis??? vinci://www.intuitive.com/en-gb/products-and-services/da-https://www.roboticthoracic.surgery/gallery-1 Postoperative Management Number 1 objective is pain management –Epidural/Paravertebral/Morphine /IV Paracetamol/NSAIDs/ Risk of surgery acquired pneumonia Early mobilisation + consistent use of incentive spirometry. MDT input. Maximizing breathing efficiency ( chest physio, DBE, bronchodilators, 02) Infections (temp spikes) Nausea Fluid volume deficiency (I+O) Laxatives Clexane Psychological support Radiotherapy • Radiofrequency Ablation (RFA). • External beam radiation. • Intensity modulated radiation therapy (IMRT). • Brachytherapy (implants) • SABR Useful in unresectable peripheral lesions and mets. Extremely useful in palliative cases. https://www.moffitt.org/cancers/lung-cancer/treatment/radiation-therapy/ High energy heat waves are transmitted from a probe into the tumour cells. Specific – SCLC can receive radiation to the brain. Stereotactic Ablative Radiotherapy (SABR) SABR Transmits radiation from many different angles around the body. The beams meet at the tumour. This means the tumour receives a high dose of radiation and the tissues around it receive a much lower dose. Indications • Small peripheral tumours. • Previous radiotherapy to that area. • Can target metastatic disease. Preparation CT scan +/- MRI or PET. Radiotherapy team including clinical oncologist puts together treatment plan. Skin markings are performed to act as a reference point. If required masks or moulds are constructed. Procedure Performed using a Linear Accelerator. Length of time – 15 mins to >2 hours. https://www.researchgate.net/figure/Stereotactic-ablative- The robotic arm moves directing radiation from various angles. body-radiotherapy-SABR-for-a-single-metastatic-lung-tumor- The_fig2_295099711 Chemotherapy Again extremely variable. Regimes can also include: Adjuvant, neoadjuvant and palliative. • Doxorubicin • Cyclophosphamide • Vinblastin NSCLC Dual Regime • Paclitaxel • Cis/Carbo platin + another. • Gemcitabine, docetaxel or taxol. SCLC • Cisplatin / Etoposide Side Effects Profile Surgery Radiotherapy Chemotherapy Pain++ Radiodermatitis Alopecia Infection Lung fibrosis! Anaemia Atelectasis Pneumonitis Fatigue++ DVT - Immobility Oesophagitis Peripheral Neuropathy Haemorrhages Decreased Oral Intake Toxicity Immunotherapy Class of treatments that helps a person’s own immune system eliminate or control cancer. Targeted Antibodies Bevacizumab: a monoclonal antibody. VEGF/VEGFR pathway. NSCLC, including as a first-line therapy. https://www.nejm.org/doi/full/10.1056/NEJMoa2302983 Necitumumab: a monoclonal antibody. EGFR pathway. NSCLC including as a first-line therapy. Immunomodulators Nivolumab : a checkpoint inhibitor. PD-1/PD-L1 pathway. NSCLC and mesothelioma in combination with ipilimumab, with or without chemotherapy + NSCLC in the neoadjuvant setting in combination with chemotherapy. Pembrolizumab: a checkpoint inhibitor. PD-1/PD-L1 pathway. NSCLC, including as a first-line therapy, an adjuvant (post-surgery) therapy, https://www.nejm.org/doi/full/10.1056/NEJMoa2202170 or in combination with chemotherapy. EXTRAS Pancoast Tumour Mesothelioma Mesothelioma is a cancer of the mesothelial layer of Pancoast tumors are rare apical tumours of the lung, making up the pleural cavity that is strongly associated fewer than 3-5% of all lung cancers with asbestos exposure, builder, shipyards, mechanic. They can compress the brachial Features • Dyspnoea, weight loss, chest wall pain. plexus causing very specific symptoms: • Finger clubbing. • Severe pain in the shoulder or • 30% present as painless pleural effusion. scapula • History of asbestos exposure in 85-90%, latent • Pain in the arm and weakness period of 30-40 years. of the ipsilateral hand Investigations: CXR – CT Pleura – Effusion sample. Horner's Syndrome (sympathetic ganglion compression) Management • Miosis (small pupil) • Symptomatic • Ptosis • Chemo/surgery if operable (pleurectomy) MARS2. • Anhidrosis (loss of sweating one side) • Industrial compensation. CANNONBALL Mets "CRESP" • C: choriocarcinoma/colorectal carcinoma • R: renal cell carcinoma • E: endometrial carcinoma • S: synovial sarcoma • P: prostate carcinoma https://radiopaedia.org/articles/cannonball-metastasis-mnemonic-1Lung Volume Reduction Surgery • Master Techniques in Surgery:Thoracic Surgery: Transplantation,Tracheal Resections, Mediastinal Tumors, Extended Thoracic ResectionsSee future sessions and watch recordings at: SUPTA.UK Resources https://teachmesurgery.com/ https://www.passmedicine.com/ https://www.cancerresearchuk.org/ https://teachmeanatomy.info/ https://radiopaedia.org/?lang=gb •Master Techniques in Surgery: Thoracic •Master Techniques in Surgery: Thoracic Surgery: Transplantation, Tracheal Resections, Surgery: Lung Resections, Bronchoplasty Mediastinal Tumors, Extended Thoracic Resections Thank you! Abderrahmane El Guernaoui SUPTA – Regional Representative Mr Peter Mhandu Surgeon Supervisor SUPTA Thank you all! Any Questions :) Email: gcampbell47@qub.ac.ukCASES1)A 66-year-old man presents to ED with a 5-day history of worsening breathlessness. He also reports a headache over a similar time period. He has noticed these symptoms are worsened on bending forward. He has a long-standing cough. He has a past medical history of small-cell lung cancer, COPD, ischaemic heart disease and gout. O/E, the patient is tachypnoeic with a respiratory rate of 25 breaths/min. Oxygen saturations are 92% on room air. Pulse is 90 bpm and blood pressure is 150/85 mmHg. Temperature is 37.2ºC. You note the patient's face appears slightly flushed. The JVP is elevated. Heart sounds are normal. There are scattered crepitations in both bases, but the lungs are otherwise clear. There is bilateral pitting oedema to the calves but the patient reports this is longstanding. CXR demonstrates hyperexpanded lungs, cardiomegaly and a mass in the right upper lobe. Which of the following is the most likely explanation for this patient’s presentation?•Pulmonary embolism •Superior vena cava obstruction •IECOPD •Carcinoid Syndrome •Lambert Eaton Myasthenic Syndrome•Pulmonary embolism •Superior vena cava obstruction •IECOPD •Carcinoid Syndrome •Lambert Eaton Myasthenic SyndromeSuperior vena cava obstruction (SVCO) is an oncological emergency caused by compression of the SVC. • Dyspnoea +++ • Swelling of the face, neck and arms • Raised ICP headache • Visual disturbance • Jugular venous distension Management • Endovascular stenting • Radical chemotherapy or chemo-radiotherapy • Dexamethasone2)A 45-year-old man presents with worsening dyspnoea over several months. His past medical history includes a myocardial infarction 5 years ago, ischaemic heart disease, rheumatoid arthritis and hypothyroidism. He drinks roughly 50 units of alcohol per week. On examination, dullness to percussion is noted over the left lower chest. An X-ray confirms pleural effusion. A pleural tap is performed and the fluid is sent for analysis: Pleural Fluid Protein 40g/L 10-20 Serum Protein 63g/L 60-80 What is the most likely cause of the effusion?•Nephrotic Syndrome •Steatohepatitis •Bronchial Carcinoma •Rheumatoid Arthritis •Hypothyroidism•Nephrotic Syndrome •Steatohepatitis •Bronchial Carcinoma •Rheumatoid Arthritis •HypothyroidismFrom before pleural protein/serum protein = 40/63= 0.633) A 64-year-old man presents to his GP with abdominal pain. This has been gradually getting worse over the course of a week. He is not a regular attender to the GP , so his past medical history isn't documented. He does tell you he is recently retired from being a lorry driver. O/E you notice that this gentleman has subtle, type 1 finger clubbing and abdominal fullness which isn't tender to palpation and there is no evidence of guarding or rebound. When questioned this gentleman reveals that he has a 50 year pack history and is a current smoker. What type of lung cancer is this man most likely to have? •Adenocarcinoma •Small Cell Carcinoma •Squamous Cell Carcinoma •Large Cell Carcinoma •Carcinoid Tumour •Adenocarcinoma •Small Cell Carcinoma •Squamous Cell Carcinoma •Large Cell Carcinoma •Carcinoid TumourThe bread trail - Abdominal pain > common is common > constipation. Abdominal fullness alluded to this - Finger clubbing > lung cancer > squamous more likely - Smoking historyCavitating Lesions4)Appropriate investigations have been performed and the now confirmed squamous cell carcinoma has been staged as T1 N1 M0. Given this result which management option, at this stage, will be offered first? • Chemo-radiotherapy • SABR • VATS • Immunotherapy • Conservative Management4)Appropriate investigations have been performed and the now confirmed squamous cell carcinoma has been staged as T1 N1 M0. Given this result which management option, at this stage, will be offered first? • Chemo-radiotherapy • SABR • VATS • Immunotherapy • Conservative Management 5)A 70-year-old retired mechanic presents to his local A&E which an acute severe exacerbation of his long standing dyspnoea. He has been experiencing dyspnoea for around 4 months. Mobility is reduced due to chest pain and recently he has noticed his appetite recently has been poor. O/E breathe sounds are reduced at the left lung base. On percussion a dullness is noted. On further questioning it is found that he is a never smoker, drinks alcohol occasionally and lives at home with his wife and pet parrot. What aspect of this history lends itself to a potential lung or pleural malignancy? Pet Smoking History Age Occupation Alcohol Pet Smoking History Age Occupation Alcohol Mesothelioma Mesothelioma is a cancer of the mesothelial layer of the pleural cavity that is strongly associated with asbestos exposure. Occupations to look out for – shipyard worker, builder and mechanic. • Dyspnoea, weight loss, chest wall pain • Finger clubbing • 30% present as painless pleural effusion • History of asbestos exposure in 85-90%, latent period of 30-40 years6) You are on call in a busy district general hospital covering the medical rota. You get a bleep to attend a 65-year-old lady who was admitted 3 days ago with low oxygen saturations requiring oxygen. This lady reports that for the past 2 months she has been fatigued, especially when rising from her chair. She reports she struggles to mobilise now and as a result doesn't leave her house much. She reports having smoked heavily previously but hasn't for 3 years. O/E you note an oxygen saturation of 95% on 2L NS and a respiration rate of 22. You note a right sided monophonic wheeze on auscultation. You consult her fluid balance which reports she hasn't passed urine for 10 hours. What test could you order to explain this presentation?• Anticholinergic Receptor Antibodies • Muscle Specific Kinase Antibodies • Voltage Gated Calcium Channel Autoantibodies • Anti-nuclear Antibodies • Anti Mitochondrial Antibodies• Anticholinergic Receptor Antibodies • Muscle Specific Kinase Antibodies • Voltage Gated Calcium Channel Autoantibodies • Anti-nuclear Antibodies • Anti Mitochondrial Antibodies LambertEatonMyasthenicSyndrome This is a paraneoplastic syndrome of SCLC, caused by an antibody directed against presynaptic voltage-gated ca2+ channels in the peripheral nervous system. • In 50%, repeated muscle contractions lead to increased muscle strength (in contrast to MG) • Limb-girdle weakness (affects lower limbs first.) • Hyporeflexia • Autonomic symptoms: dry mouth, impotence, difficulty micturating. • Ophthalmoplegia and ptosis not commonly a feature (unlike in MG.)